High School Girls with AD/HD

Kathleen G. Nadeau, Ph.D.

It seems as if nature and society have conspired to pack
the high school years with so many daunting challenges that
even the most adept and well-adjusted adolescent feels overloaded.
When AD/HD is added to the mix, high school becomes even
more challenging, and may even become a destructive experience.

Diagnosis of ADD or ADHD in teenage girls

The accurate diagnosis and appropriate treatment of girls
with ADD or ADHD is acutely important in these challenging
years, however many teenage girls with AD/HD go undiagnosed
or misdiagnosed for a number of reasons:

Girls with AD/HD often behave very differently
than boys, falling into the much harder to diagnose category
of "primarily inattentive type;"

Girls typically work harder to hide their academic difficulties
and to conform to teacher expectation; and

Girls are often misdiagnosed as anxious and/or depressed.

Girls who are particularly bright are able to compensate
for their AD/HD much longer, and are therefore the
most likely candidates for a late diagnosis.

The fact that a girl's AD/HD symptoms may not have
been apparent in early years renders her AD/HD no less
real when it rears its head in adolescence, a time when the
demands for planning, organization, recall, and focus intensify.
There have been numerous discussions of the need for gender-based
diagnostic criteria for AD/HD, but for now, professionals
continue to rely on criteria that serve much better to identify
boys than girls.

Parents who may suspect that their teenage daughter may
have AD/HD can have her complete the questions our self-questionnaire. If your daughter answers "yes" to many
of these questions, a careful assessment for AD/HD should be undertaken.

Troubling challenges faced by teenage girls
with AD/HD

Many of the issues discussed below also present challenges
for girls without AD/HD. However, these issues seem to
be more intense and more frequent among girls who face the
double challenges of adolescence and AD/HD.

Social pressures

Girls with AD/HD experience social deficits as early
as preschool years, but they seem to reach their greatest
impact during adolescence as girls begin to separate from
family and social life takes on a greaterimportance. Many
women with AD/HD recall feeling "different"
from other girls when growing up. The need for peer acceptance
during high school years is intense and may lead to dangerous
or self-destructive behavior in an effort to "belong."

Low self-esteem

Family support and acceptance is critical, but can never
entirely counteract the damage that can be done to teenagers
who feel rejected by their peer group. Girls with AD/HD
may develop low self-esteem in high school years that can
haunt them for years afterwards.

Inability to meet social expectations

While teenage years are full of self-doubts for most girls,
the special challenges of AD/HD greatly intensify those
feelings. For example, girls are typically encouraged to be
neat, "feminine" (controlled and passive), carefully
groomed (in order to be attractive to the opposite sex), sensitive
to the feelings of others, and compliant with adults. These
very expectations are often in direct opposition to the AD/HD tendencies of many girls.

A teenage girl with AD/HD may respond anxiously, even
obsessively, to the expectation that she be well groomed and
fashionably dressed, yet be unable to organize her room or
her life well enough to have clean, color-coordinated clothing
available on a given school morning.

Emotional reactivity/ Hormonal Fluctuations

The typical hyper-reactivity of AD/HD tends to increase
in adolescence as hormonal fluctuations complicate and escalate
reactivity. As a result, the self-doubts and competitiveness
so common among teenage girls are often more intense for girls
with AD/HD. Their hurt feelings can escalate more rapidly
into impulsive remarks or over reactions. Once the drama is
over, she may be ready to forgive and forget. The friends
and family who are stung by her comments, however, often become
intolerant of her outbursts.

Depression

Social pressures are intense during adolescence, with enormous
energy expended on peer analysis: watching, imitating, relating,
comparing, and conforming. In addition to this exhausting
list, girls with AD/HD often feel despair. Depression,
common among women with AD/HD, often begins during the
pressures of teen years. Such depression is much easier to
recognize, and many girls with AD/HD find themselves
treated for depression while their AD/HD goes unrecognized.

Growing Pressures to "mature"

Pressure to grow up and become responsible increase during
adolescence. Sometimes parental expectations for their daughters
to demonstrate "maturity" can come into direct conflict
with the neurocognitive patterns associated with AD/HD.
This doesn't mean that our daughters can't become "mature,"
but it does mean that maturity needs to be viewed through
an AD/HD lens.

High school and AD/HD - not a good "fit"

Academic pressures seem to reach a crescendo in high school,
as well. High school is designed in a way that seems almost
diabolically structured to be ADD-unfriendly. The day starts
too early and lasts too long - with demands for focus and
concentration that far exceed the capacity of most students,
even those without AD/HD. In addition, any students with
AD/HD are placed in the position of being forced to read
and study about subjects that hold little or no interest for
them - something they will be strongly advised against doing
once they have graduated from high school!

Sexual risks

Teenage girls with AD/HD may be at greater risk for
pregnancy than are other teenage girls (Arnold, 1996). This
may be true for a number of reasons. Teenage girls who struggle
with low self-esteem, as do many girls with AD/HD, often
seek affirmation through the sexual attentions of boys in
an effort to compensate for feelings of inadequacy in other
areas of their life. Furthermore, due to difficulties with
impulse control, poor planning ability, and inconsistency,
many of these girls are prone to have unprotected sex, use
birth control inconsistently, and/or have multiple partners.

Risks associated with driving

Studies of teens with AD/HD have shown that, in general,
they have a greater likelihood of being involved in traffic
accidents. Most studies have only examined the driving behavior
of boys with AD/HD, but one study in New Zealand (Nada-Raja
et al, 1997) studied both boys and girls and found that girls
with attentional difficulties were at high risk for both traffic
crashes and driving offenses.

Risk for substance abuse and addictive behaviors

The risk for substance abuse and other addictive behaviors
(cigarette smoking, eating disorders) typically begins in
the middle school years and intensifies during high school.
A recent study (Biederman et al., 1999) reports that 14% of
girls with AD/HD have a substance use disorder and one
in five smoked cigarettes.

How Can Parents and Professionals Help?

Managing the emotional roller coaster

It is critical that parents and professionals recognize
that the intensity so often seen in teenage girls with AD/HD has a neurological basis, and that reactions tend to
become even more extreme during times of stress, fatigue,
hunger, or PMS. Both the teenage girl and her parents need
to recognize the added vulnerability that she has, and begin
to identify and manage the potential stresses that can worsen
her reactions.

Both medication and psychotherapy, used in conjunction,
seem to be the most effective treatment program. Medication
regimens often need to address a complex set of issues, including
anxiety and/or depression, rather than AD/HD alone.

Because peer issues and issues of self-worth are so paramount
among most teenage girls with AD/HD, psychotherapy needs
to be designed to directly address these. Often, group psychotherapy
can be tremendously supportive and effective for teenage girls
with AD/HD. Such a group might be conducted at school
by a school counselor, or might be found in a private clinic
setting.

Treating Pre Menstrual Syndrome (PMS)

Tremendous hormonal changes occur, and the hormonal fluctuations
of the menstrual cycle intensify and complicate the confusion
and unpredictability that are part and parcel of growing up
with AD/HD. While Pre-Menstrual Syndrome (PMS) may be
an annoying period of irritability, fatigue, or cramping for
many girls, those with AD/HD may feel such an increase
in the intensity of their emotional reactions, irritability,
and low frustration tolerance that they require active intervention.
Physicians, therapists and others who treat adolescent girls
with AD/HD should be aware of this added vulnerability,
and take steps to keep up-to-date on research on PMS and new
approaches for minimizing its impact. The use of anti-depressant
medication to combat the effects of PMS is fairly well-known,
but recent research has suggested that there are a number
of ways to reduce PMS symptoms in the more vulnerable AD/HD population.

Reducing the risk of anxiety and depression

Emotions can tip quickly when environmental stresses suddenly
overwhelm the teenage girl's already distressed system. An
accidental pregnancy, the breakup of a relationship, a failed
exam, a rejection letter from a college - any of these might
be enough to push her into levels of anxiety or depression
that may require both medication and psychotherapy. Parents
and professionals need to be watchful during the teenage years
to assess whether the "normal" emotional roller
coaster for girls with AD/HD has careened over the edge
into a level of anxiety or depression that requires treatment
in tandem with her treatment for AD/HD. Both anxiety
and depression are common among teenage girls with AD/HD
and can be successfully treated along with the AD/HD.
The experienced physician will be aware that stimulant medication
for AD/HD may tend to increase anxiety, and should prescribe
appropriate anti-anxiety medication accordingly.

Reducing Sexual Risks

What can parents and professionals do to help reduce sexual
risks for girls with AD/HD? Support groups for girls
with AD/HD can help them feel more accepted and less
alone without them having to seek male sexual attention. Helping
them become involved in structured, constructive activities
will give them other outlets to develop self-esteem. Recent
studies confirm what common sense tells us: adolescents who
are kept busy in extracurricular activities, sports, church
groups, and so on are less likely to get in trouble during
high school. In addition, an open, supportive relationship
with their parents gives them somewhere to turn for advice
if they do become sexually active - either to help them make
a wise choice of birth control or to help make the best decision
if they do accidentally become pregnant.

Reducing risks associated between AD/HD and driving

The important message for parents is that their daughters
with AD/HD may need more practice in driving so that
driving skills become more automatic and require less concentrated
effort and attention. Secondly, since attention problems seem
to be strongly implicated in traffic accidents, girls (and
boys) with AD/HD should take care to drive in less distracting
situations during their first years as a driver. They should
avoid heavy traffic, social distractions, such as excited,
talkative peers, and maintain more conscious awareness of
their need to "keep their eyes on the road." Even
in adulthood, individuals with AD/HD may find themselves
distracted by conversation while driving. For less experienced
drivers, such a distraction could be all it takes to trigger
a chain reaction leading to an accident. Thirdly, situations
that may lead to impulsive reactions should be discussed in
advance and avoided, if possible. Such situations might include
driving with peers who have been drinking and who may encourage
a teenage girl with AD/HD to take a risk "for fun."
Parents who have reason to suspect that their daughter engages
in alcohol or drug abuse should carefully consider whether
it is safe to allow their daughter to begin driving independently
as early as her peers.

Learning to recognize and to embrace her strengths

Girls who have developed ability or talent in some area
seem to be much better inoculated against clouds of self-defeating
gloom. One of the most constructive approaches in helping
a girl with AD/HD through her high school years is to
actively help her develop and recognize areas of competence
and talent. The more that girls with AD/HD are in touch
with their areas of competence the less vulnerable they will
be to the criticisms and frustrations that so often accompany
AD/HD.

There are many arenas in which to develop a sense of competence
and ability: part-time work after school, volunteer work,
helping to build props for the school play, participating
in a community beautification project, learning to ride horseback
- many such activities can be enormously beneficial in helping
her to build a sense of self-confidence.

Learning assertiveness and self-advocacy

The high-school years are the time in which a girl needs
to develop the self-advocacy skills needed for more independent
life beyond high school - whether in an educational setting
or in the workforce. She will need to be able to express her
needs confidently and convincingly to professors or employers
who are ill- informed about AD/HD. She needs validation
of her right to express her opinion, and help in learning
to express it in a constructive, effective manner.

The benefits of structure

As with girls of all ages with AD/HD, teenage girls
need support, encouragement, and structure. Because teenage
girls are trying to develop more independence, sometimes it
is more helpful when someone other than her parents provides
structure. This could be a therapist, coach, or school guidance
counselor. These are the years when the teenage girl needs
to take on the notion that learning to be on time, developing
tools to improve her organization, setting priorities rather
than staying in a reactive mode, are for her own benefit,
not something imposed by parents.

Conclusion

High-school years can be very challenging for girls with
AD/HD. To meet these challenges, girls with AD/HD need
support from peers, parents, and schools, combined with appropriate
medical and psychological treatment, depending on their particular
needs and issues. With the right supports and interventions,
these girls can make the crucial transition from the chaos
and self-doubt of adolescence to a sense of growing strength,
efficacy, and competence as they enter their young adult years.

Resources for Teenage Girls with AD/HD:

Understanding
Girls with ADHD by Kathleen Nadeau, Ph.D., Ellen Littman,
Ph.D. and Patricia Quinn, M.D. provides more in-depth information
about the issues and challenges of teenage girls with ADHD.

Help4ADD@HighSchool
by Kathleen Nadeau, Ph.D. is written for teens in a very readable,
ADD-friendly format providing information and coping strategies
to help teens meet the challenges of ADD during their high
school years.

Adolescence and
ADD by Patricia Quinn, M.D. is written for both teens
and their parents to help them understand ADD (ADHD) during
high school years as well as help them prepare for the transition
to college.

The Girls' Guide to AD/HD by Beth Walker is a book for teen girls that covers many important issues including: What ADHD is like for girls; how counseling, coaching, and medications help; ways to cope with school and homework: and how to get along with friends and family.